Provider Demographics
NPI:1073173597
Name:IVY, JULIANNE ALICE (MD)
Entity Type:Individual
Prefix:
First Name:JULIANNE
Middle Name:ALICE
Last Name:IVY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 600
Mailing Address - Street 2:
Mailing Address - City:TUBA CITY
Mailing Address - State:AZ
Mailing Address - Zip Code:86045-0600
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:167 NORTH MAIN STREET
Practice Address - Street 2:
Practice Address - City:TUBA CITY
Practice Address - State:AZ
Practice Address - Zip Code:86045
Practice Address - Country:US
Practice Address - Phone:928-283-2679
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-17
Last Update Date:2022-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2019018901208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics